Inspection Reports for
Edencrest at Beaverdale

Complaint #130521-C

The program failed to follow its established policy for documenting food temperatures. Multiple tenants reported that hot food was sometimes served too cool, and staff did not maintain required food temperature logs.

Complaint #129336-C was investigated and found to have no regulatory insufficiencies.

No regulatory insufficiencies were cited during the complaint investigation.

The program failed to consistently maintain accurate documentation of personal and health-related care task sheets for tenants with cognitive impairment, specifically failing to document safety checks as required by tenants' service plans. This deficiency was confirmed through record reviews and interviews.

Complaint #123900-C was investigated with no regulatory insufficiencies cited from Incident 119799-I. The complaint investigation identified multiple regulatory insufficiencies related to medication labeling, storage, service plan signatures, and door alarms.

The Program failed to consistently follow policies regarding medication labeling and storage, tenant service plan signatures, and ensuring operating door alarms on exit doors. Specific deficiencies included unlabeled insulin pens without date documentation, medications not stored in locked locations, unsigned tenant service plans, and non-functioning door alarms on exit doors.

The complaint investigation involved multiple complaints (#115644-C and #116396-C). No regulatory insufficiencies were found in other complaints and incidents (#115247-I, #115688-I, #115689-I, #113050-C, #115289-C, #116290-C).

The investigation found regulatory insufficiencies including failure to consistently ensure tenants received medications as prescribed and failure to ensure a tenant with unmanageable incontinence continued to meet criteria to remain in the assisted living program.

The investigation was triggered by Complaint #110810-C. The complaint was substantiated by findings that contract staff did not have required dementia-specific education.

The program failed to consistently ensure all personnel, including contract/agency staff, were appropriately trained to meet tenant needs, specifically lacking dementia-specific training for three reviewed staff members, potentially affecting 35 tenants with cognitive impairment.

The investigation was triggered by Incident #108535-I and Complaint #108537-C. No regulatory insufficiencies were cited during investigations of Complaints #108492-C or #108781-C. The complaint was substantiated with findings related to elopement and service plan deficiencies.

The program failed to follow established policies and procedures regarding elopement for one tenant, including failure to develop a service plan prior to occupancy and failure to respond appropriately to door alarms. Staff did not conduct required head counts or properly monitor the tenant who eloped.

Investigations #108492-C, 108781-C, 108535-I, 108537-C

The program failed to follow its elopement policies and procedures, resulting in Tenant #1 exiting the memory care unit unnoticed by staff. Staff failed to conduct timely checks and head counts after door alarms, and the tenant was found outside by police. Training and service plans related to elopement were lacking.

The investigation into Complaint #103179-C found no regulatory insufficiencies. The complaint investigation related to Incident #104977-I identified deficiencies in service plans, supervision, and alarm system functionality.

The program failed to consistently ensure service plans included tenants' identified needs affecting 3 of 9 tenants reviewed. The program also failed to properly supervise tenants according to their service plans, specifically one tenant who eloped from the facility. Additionally, the program failed to have an operating alarm system on the front door, potentially affecting all tenants.

The program failed to properly supervise Tenant #1 according to his service plan, resulting in an elopement lasting over three hours. The program also failed to have an operating alarm system on the front door during the incident, potentially affecting all tenants.

The investigation of complaints #98769 and 99631 found no regulatory insufficiencies. The incident investigation #100073 found a deficiency related to tenant elopement.

No regulatory insufficiencies were found during the complaint investigations and infection control review. However, a deficiency was cited for failing to ensure a safe environment when a tenant eloped from the program. The facility had issues with gate codes and gate malfunctions that allowed the tenant to leave unsupervised.

The program failed to ensure a safe environment when Tenant #1 eloped from the memory care unit. The investigation found that the patio gate was accessible to families who had the code, and staff were unable to determine exactly how the tenant left the premises.

Investigation involved complaints 93271-C, 93965-C, and 94460-C; no deficiencies were found.

No regulatory insufficiencies were cited during the investigation and infection control survey.

No regulatory insufficiencies were cited during the recertification inspection.